Comprehensive Interdisciplinary Senior Assessment Programs: An Overview

Taryn Lee, MD is board-certified in geriatric medicine and is the medical director of Geriatric Medicine at University Hospitals Bedford Medical Center.

While a standard medical evaluation serves reasonably well in most patient populations, they tend to work less well for older patients who in addition to their medical conditions, may experience cognitive, functional and psychosocial concerns.

The Senior Assessment is a multidisciplinary evaluation of functional ability, physical health, cognition and mental health, as well as social and environmental circumstances. This broadly based inquiry differs from a standard medical evaluation by including nonmedical domains, and emphasizes functional capacity and quality of life. It is particularly effective in identifying health conditions, safety issues and cognitive changes which can impact an individual’s ability to live independently.

The assessment team may include a geriatrician, nurse or nurse practitioner, social worker, physical therapist, occupational therapist, nutritionist and pharmacist, yielding a more complete and relevant perspective of medical, functional and psychosocial issues. Results may aid in developing individualized plans of care to manage and prevent or delay complications arising from issues identified via the assessment.

Specifically, the Senior Assessment Team may evaluate for:

  • Physical health and disease: The medical history, physical examination, and diagnostic testing help to confirm and/or detect medical problems that can affect the patient’s health and function.
  • Activities of Daily Living (ADLs): By determining the patient’s ability to carry out his/her ADLS such as bathe, dress, toilet, perform housework, handle finances, manage medications, prepare meals, drive, etc., the team can identify areas where additional functional assistance is needed.
  • Fall risk: A falls evaluation often finds a multifactorial etiology and the team may recommend modifications in medications, environment, assistive device use, footwear and/or referral to specialists such as neurology and physical therapy for further evaluation and treatment.
  • Memory impairment: Screening for memory loss may suggest an early diagnosis, which in turn will allow patients access to treatments that may slow down cognitive decline. Counseling may also be offered to help patients/caregivers manage related symptoms and make preparations for the future.
  • Depression/Anxiety: Detection and treatment of mood disorders may lead to improved cognition, pain symptoms and function.
  • Polypharmacy: Asking patients to bring in all their medications (including non-prescription pills) allows the team to conduct a complete review of their medication regimen. Efforts are made to reduce unnecessary medications that can cause unwanted adverse effects and interactions.
  • Nutrition/weight change: Screening for weight changes and nutritional concerns can lead to detection of underlying medical, dental, financial, cognitive, social, and medication problems.
  • Urinary incontinence: Recognizing this condition can result in adjustment of medications, improved hygiene and skin care, increased function and referral for further specialist evaluation.
  • Vision/hearing impairment: Addressing sensory deficits may enrich communication, interaction with others and quality of life.
  • Living situation: Assessing optimal living arrangements and social support availability may lead to counseling about community resources that can enhance one’s ability to live safely in the community.
  • Advance care planning: Asking about advance directives and wishes about end of life care may help patients and families make better informed decisions when changes in health status and care needs occur.

Given the growth in senior populations, more providers will be caring for patients with health related issues commonly seen in older patients. To screen and tackle these concerns requires time and an interdisciplinary coordinated care approach by multidisciplinary team members. The Comprehensive Senior Assessment can positively impact healthcare delivery by assisting providers, caregivers, and patients to address their questions proactively. By evaluating and managing needs early and holistically, the Senior Assessment Team can improve the quality, efficiency and effectiveness of care for the older patient.

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